Student Enrollment Form

First Name *

Last Name *

Date of birth *

Email *

Student Cell Phone *

I agree to terms & conditions provided by the Community Youth Development Institute (CYDI). By providing my phone number, I agree to receive text messages from CYDI.

Street Address *

City *

State *

Postal code *

Sex at Birth *

Male

Female

Prefer not to answer

Preferred Gender *

Male

Female

Transgender

I use a different term

Prefer not to answer

Race/Ethnicity *

American Indian or Alaskan Native

Asian

Black/African American

Hawaiian or Pacific Islander

Hispanic

White

Prefer not to answer

Previous School Information

Previous School Name *

Grade Level *

Number of Credits Earned *

Reason For Leaving Previous School *

Additional Student Information

Number of children? *

0

1

2

3

4

Who is your daycare provider?

Are you receiving any teen parent services?

Yes

No

Are you on probation or parole? *

Yes

No

P.O. Name and Number?

Are you on section 8? *

Yes

No

How Did You Learn About CYDI? *

Flyer

UCCS Lottery

Student

Faculty / Staff

YS3 Program

Social Media

Parent / Guardian Information

Primary Parent / Guardian Name: *

Primary Parent / Guardian Phone: *

Primary Parent / Guardian Email: *

Primary Parent / Guardian Relation To Student? *

Alternate Parent / Guardian Name:

Alternate Parent / Guardian Phone:

Alternate Parent / Guardian Email:

Alternate Parent / Guardian Relation To Student?

Required Documents

The below document copies are required to enroll at the Community Youth Development Institute High School. We take you privacy seriously. Our privacy policy can be viewed here: https://www.cydihs.org/privacy-policy

Student Drivers License / State ID

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Guardian Drivers License / State ID

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Student Social Security Card

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Student Birth Certificate

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Proof of Residency (Utility Bill / Lease)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Transcript

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

ISBE Release

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Medical Records

Physical Record

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Current Shot Record

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Asthma Action Plan (If applicable)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Form Submitted By: *

Enrollment Form Signature *

I certify that the information provided herein is true, correct, and complete to the best of my knowledge.

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